Khaled R. Girgis, MD, PhDKhaled R. Girgis, MD, PhDAllergist and Clinical Allergist and Clinical

ImmunologistImmunologist

College Park Family Care College Park Family Care CenterCenter

12208 W 8712208 W 87thth Street Street

Lenexa, KS 66215Lenexa, KS 66215

Allergic RhinitisAllergic Rhinitis

Everything you need to Everything you need to know, almostknow, almost

Allergic Rhinitis, FactsAllergic Rhinitis, Facts

• More than 50 million Americans More than 50 million Americans suffer from allergiessuffer from allergies

• Sixth leading chronic disease in U.S.Sixth leading chronic disease in U.S.

• 4.5 billion dollars in health care costs 4.5 billion dollars in health care costs annuallyannually

• 3.8 million days lost yearly (from 3.8 million days lost yearly (from work and school)work and school)

What is Rhinitis?What is Rhinitis?

• The nasal passages are lined with a The nasal passages are lined with a membrane that produces mucusmembrane that produces mucus

• Mucus is one of the body's defense systems:Mucus is one of the body's defense systems:– Thin clear liquid, traps small particles and Thin clear liquid, traps small particles and

bacteria bacteria – The trapped bacteria usually remain harmless in The trapped bacteria usually remain harmless in

healthy individualshealthy individuals– Even under normal circumstances, this produces Even under normal circumstances, this produces

a cycle of congestion and decongestion that a cycle of congestion and decongestion that occurs continuously throughout the dayoccurs continuously throughout the day

• When one side of the nose is congested, air When one side of the nose is congested, air passes through the open, or decongested, passes through the open, or decongested, side. The sides alternate between being side. The sides alternate between being wide open and being narrowedwide open and being narrowed

Allergic Rhinitis:Allergic Rhinitis:Effect On Quality of LifeEffect On Quality of Life

• People with perennial allergic rhinitis, may People with perennial allergic rhinitis, may experience sleep disorders and daytime experience sleep disorders and daytime fatigue.fatigue.– Often they attribute this to medication, but Often they attribute this to medication, but

studies suggest congestion may be the culprit in studies suggest congestion may be the culprit in these symptoms. these symptoms.

• Patients with seasonal allergies experience Patients with seasonal allergies experience hundreds of brief, subtle awakenings, called hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, "microarousals", each night. In such cases, people are not aware that they wake up, but people are not aware that they wake up, but such events can cause fatigue the next day.such events can cause fatigue the next day.

Allergic Rhinitis:Allergic Rhinitis:Effect On Quality of LifeEffect On Quality of Life

• Children with severe allergies may have a higher risk for Children with severe allergies may have a higher risk for behavioral problems than those without allergiesbehavioral problems than those without allergies

• There have been reports that 30% to 45% of people with There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media)allergic rhinitis also suffer from ear infections (otitis media)

• Chronic nasal obstruction can affect a child's appearance. If Chronic nasal obstruction can affect a child's appearance. If a child can only breathe through the mouth, this might lead a child can only breathe through the mouth, this might lead to an elongated face and an overbite from teeth coming in to an elongated face and an overbite from teeth coming in at an abnormal angleat an abnormal angle

• Chronic rhinitis can cause headaches and also affect a Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growthchild's sleep, concentration, hearing, appetite, and growth

Allergic Rhinitis: Risk FactorsAllergic Rhinitis: Risk Factors

• Increasing age, atopy, and high Increasing age, atopy, and high socioeconomic statussocioeconomic status

• Parental history is also positively Parental history is also positively associated with development of associated with development of allergic rhinitis. A maternal history of allergic rhinitis. A maternal history of allergy was significantly associated allergy was significantly associated with a diagnosis of rhinitis by age 6 with a diagnosis of rhinitis by age 6 years years

• Other risk factors include indoor and Other risk factors include indoor and outdoor air pollutionoutdoor air pollution

Sagittal view of the inside of the nasal cavitySagittal view of the inside of the nasal cavity

Allergic Rhinitis: MechanismAllergic Rhinitis: Mechanism

Allergic Rhinitis: SymptomsAllergic Rhinitis: Symptoms

• RhinitisRhinitis develops when congestion becomes severe develops when congestion becomes severe or other changes occur that irritate the nasal or other changes occur that irritate the nasal passagepassage

• Patient must experience at least two of the Patient must experience at least two of the following symptoms for an hour or more on most following symptoms for an hour or more on most days:days:– Runny noseRunny nose– Obstruction in the nasal passageObstruction in the nasal passage– Nasal itchingNasal itching– SneezingSneezing

• These symptoms may occur as a result of colds or These symptoms may occur as a result of colds or environmental irritants, such as allergens, environmental irritants, such as allergens, cigarette smoke, chemicals, changes in cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factorstemperature, stress, exercise, or other factors

The Allergic AppearanceThe Allergic Appearance: :

Allergic shiners related to chronic nasal congestionAllergic shiners related to chronic nasal congestion Mouth breathing and a gaping mouth Mouth breathing and a gaping mouth

The Allergic SaluteThe Allergic SaluteNasal itching causes repeated wiggling of Nasal itching causes repeated wiggling of

the nose (bunny nose), or wiping and the nose (bunny nose), or wiping and pushing of the nosepushing of the nose

Chronic RhinitisChronic Rhinitis

• When rhinitis lasts for a long period, When rhinitis lasts for a long period, it is most often caused by allergies it is most often caused by allergies but can also be caused by structural but can also be caused by structural problems or chronic infections.problems or chronic infections.

Chronic Rhinitis Not Related to Chronic Rhinitis Not Related to AllergiesAllergies

• Aging ProcessAging Process

• Mucous membranes become dry with age Mucous membranes become dry with age

• Cartilage supporting the nasal passages Cartilage supporting the nasal passages weakens, causing changes in airflowweakens, causing changes in airflow

• Therapy:Therapy:

Avoid possible allergens and airborne Avoid possible allergens and airborne irritants and keep the nasal passages irritants and keep the nasal passages moist. Decongestants would not be moist. Decongestants would not be appropriateappropriate

Vasomotor Rhinitis: Chronic Vasomotor Rhinitis: Chronic Rhinitis Not Related to AllergiesRhinitis Not Related to Allergies

• Increased parasympathetic Increased parasympathetic stimulationstimulation

• Overreaction to irritants, cigarette Overreaction to irritants, cigarette smoke, air pollutants, strong odors, smoke, air pollutants, strong odors, alcoholic beverages, stress, and alcoholic beverages, stress, and exposure to cold exposure to cold

• Gustatory rhinitisGustatory rhinitis

• Not the same as allergic reactionNot the same as allergic reaction

Chronic Rhinitis Not Related to Chronic Rhinitis Not Related to AllergiesAllergies

• Foreign ObjectsForeign Objects

• Blockage in young children is very Blockage in young children is very often caused by foreign objects often caused by foreign objects

• If left in place, they may eventually If left in place, they may eventually cause infection and nasal discharge, cause infection and nasal discharge, usually in one side of the nose, which usually in one side of the nose, which may be yellow or green and foul may be yellow or green and foul smelling (very)smelling (very)

Chronic Rhinitis Not Related to Chronic Rhinitis Not Related to AllergiesAllergies

• PolypsPolyps– soft, fluid-filled sacssoft, fluid-filled sacs– impede mucus drainage and restrict airflowimpede mucus drainage and restrict airflow– develop from sinus infections, do not regress on develop from sinus infections, do not regress on

their own and may multiply and cause their own and may multiply and cause considerable obstructionconsiderable obstruction

• Deviated SeptumDeviated Septum– A common structural abnormality that causes A common structural abnormality that causes

rhinitis When deviated, it is not straight but rhinitis When deviated, it is not straight but shifted to one side, usually the leftshifted to one side, usually the left

Nasal PolypsNasal Polyps

• Protrude from the sinuses into the Protrude from the sinuses into the nasal cavities, usually from the nasal cavities, usually from the middle meatusmiddle meatus

• Can be unilateral, or bilateralCan be unilateral, or bilateral

• Anosmia, most common presentationAnosmia, most common presentation

• Very common in CFVery common in CF– 50% of children (4-16 y/o) w/ nasal 50% of children (4-16 y/o) w/ nasal

polyps have CFpolyps have CF

Rhinitis of PregnancyRhinitis of Pregnancy

• One in five pregnant women will One in five pregnant women will experience rhinitis symptoms (2experience rhinitis symptoms (2ndnd or or 33rdrd trimester) trimester)

• Hormonally inducedHormonally induced

• Spontaneously resolves within few Spontaneously resolves within few weeks after deliveryweeks after delivery

• Limited therapeutic optionsLimited therapeutic options

Drug-Induced RhinitisDrug-Induced Rhinitis Chronic Rhinitis Not Related to Chronic Rhinitis Not Related to

AllergiesAllergies

• Medications and Illegal DrugsMedications and Illegal Drugs• overuse of overuse of decongestant spraysdecongestant sprays can, over time (three can, over time (three

to five days), cause inflammation in the nasal to five days), cause inflammation in the nasal passages and worsen rhinitis, passages and worsen rhinitis, Rhinitis Rhinitis MedicamentosaMedicamentosa

• Aspirin, IbuprofenAspirin, Ibuprofen (Motrin, Advil), and Naproxen (Motrin, Advil), and Naproxen (Aleve) For minor pain, Acetaminophen (e.g., (Aleve) For minor pain, Acetaminophen (e.g., Tylenol), is usually recommended for patients with Tylenol), is usually recommended for patients with intolerance to NSAIDs. intolerance to NSAIDs.

• Oral contraceptives, hormone replacement therapy, Oral contraceptives, hormone replacement therapy, anti-anxiety agents, some antidepressants, and some anti-anxiety agents, some antidepressants, and some blood pressure medications, including beta-blockers blood pressure medications, including beta-blockers and vasodilatorsand vasodilators

• Sniffing Sniffing cocainecocaine damages nasal passages and can damages nasal passages and can cause chronic rhinitiscause chronic rhinitis

Local Allergic RhinitisLocal Allergic Rhinitis

• Patients demonstrate Allergic Rhinitis Patients demonstrate Allergic Rhinitis symptoms but without other symptoms but without other systemic manifestations systemic manifestations

• Negative SPT and negative RASTNegative SPT and negative RAST

• Diagnosis: Nasal provocation and Diagnosis: Nasal provocation and detection of specific IgE in nasal detection of specific IgE in nasal mucosa mucosa

Allergic Rhinitis: DiagnosisAllergic Rhinitis: Diagnosis

• Allergy TestingAllergy Testing– Skin testing and in-vitro blood testingSkin testing and in-vitro blood testing– Testing is important to institute specific Testing is important to institute specific

avoidance measuresavoidance measures– Skin testing is slightly more sensitive Skin testing is slightly more sensitive – Common allergensCommon allergens

•Outdoors: tree, grass, weed pollens, and Outdoors: tree, grass, weed pollens, and moldmold

• Indoors: dust mites, pet dander, Indoors: dust mites, pet dander, cockroaches and moldcockroaches and mold

Allergic Rhinitis: DiagnosisAllergic Rhinitis: Diagnosis

• Imaging studiesImaging studies– X-rays have a limited valueX-rays have a limited value– CT scans are preferred for evaluation of CT scans are preferred for evaluation of

sinusitissinusitis

• EndoscopyEndoscopy– Usually performed by an ENT physician, Usually performed by an ENT physician,

allows easy evaluation of the nose, and allows easy evaluation of the nose, and throat areasthroat areas

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Indoor ProtectionAvoidance/Indoor Protection

• Pets:Pets:– If patient is allergic to pets, they should be given away If patient is allergic to pets, they should be given away

or kept outside or kept outside – If this isn't possible, they should at least be confined to If this isn't possible, they should at least be confined to

carpet-free areas outside the bedroom carpet-free areas outside the bedroom – Cats harbor significant allergens, which can even be Cats harbor significant allergens, which can even be

carried on clothing; dogs usually present fewer problems carried on clothing; dogs usually present fewer problems – Washing animals once a week can reduce allergens. Dry Washing animals once a week can reduce allergens. Dry

shampoos, such as Allerpet, are now available for pets shampoos, such as Allerpet, are now available for pets that remove allergens from skin and fur and are easier that remove allergens from skin and fur and are easier to administer than wet shampoos.to administer than wet shampoos.

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Indoor ProtectionAvoidance/Indoor Protection

• Dust Control Dust Control – simply using a spray furniture polish is very simply using a spray furniture polish is very

effective for reducing both dust and allergenseffective for reducing both dust and allergens– Air cleaners, filters for air conditioners, and Air cleaners, filters for air conditioners, and

vacuum cleaners with HEPA filters can help vacuum cleaners with HEPA filters can help remove particles and small allergens found remove particles and small allergens found indoorsindoors

– Neither vacuuming nor the use of anti-mite Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in carpet shampoo, however, is effective in removing mites in house dust. In fact, removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergensvacuuming stirs up both mites and cat allergens

– Carpets and rugs should be avoided if possibleCarpets and rugs should be avoided if possible

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Indoor ProtectionAvoidance/Indoor Protection

• Bedding and CurtainsBedding and Curtains– Using semipermeable coverings to fully Using semipermeable coverings to fully

encase mattresses, box-springs and encase mattresses, box-springs and pillows is the most proven effective step pillows is the most proven effective step in reducing dust mite levelsin reducing dust mite levels

– Curtains should be replaced with shades Curtains should be replaced with shades or blindsor blinds

– Bedding should be washed using the Bedding should be washed using the highest temperature settinghighest temperature setting

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Indoor ProtectionAvoidance/Indoor Protection

• Reducing Humidity in the House Reducing Humidity in the House – Dust mites thrive in humidity and damp Dust mites thrive in humidity and damp

houses increase the risk for moldhouses increase the risk for mold– On-going humidifiers, then, can be On-going humidifiers, then, can be

counterproductive. If they are used, counterproductive. If they are used, humidity levels should not exceed 40% humidity levels should not exceed 40% and they should be cleaned daily with a and they should be cleaned daily with a vinegar solutionvinegar solution

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Indoor ProtectionAvoidance/Indoor Protection

• Exterminating PestsExterminating Pests– Cockroaches: eliminate by professional Cockroaches: eliminate by professional

exterminators. (One study reported that ridding exterminators. (One study reported that ridding a home of cockroaches and cleaning the house a home of cockroaches and cleaning the house using standard housecleaning techniques failed using standard housecleaning techniques failed to eliminate the cockroach allergens to eliminate the cockroach allergens themselves.) themselves.)

– Mice should be eliminated, attempts should be Mice should be eliminated, attempts should be made to remove all dust, which might contain made to remove all dust, which might contain mouse urine and dander.mouse urine and dander.

Allergic Rhinitis: TreatmentAllergic Rhinitis: TreatmentAvoidance/Outdoor ProtectionAvoidance/Outdoor Protection

• Camping and hiking trips should not be Camping and hiking trips should not be scheduled during times of high pollen count scheduled during times of high pollen count (in the Northern states, May and June for (in the Northern states, May and June for grass pollen and mid-August to October for grass pollen and mid-August to October for ragweed).ragweed).

• Patients who are allergic to mold should Patients who are allergic to mold should avoid barns, hay, raking leaves, and mowing avoid barns, hay, raking leaves, and mowing grass.grass.

• Fungi in car air conditioners can also be a Fungi in car air conditioners can also be a problem.problem.

Allergic Rhinitis: Medical Allergic Rhinitis: Medical TreatmentTreatment

Allergic Rhinitis:Allergic Rhinitis:Second-Generation (Nonsedating) Second-Generation (Nonsedating)

AntihistaminesAntihistamines• The newer second-generation antihistamines do not usually The newer second-generation antihistamines do not usually

cause drowsiness to the extent that the first generation cause drowsiness to the extent that the first generation antihistamines do.antihistamines do.

• Brand Names.Brand Names. – Loratadine (Claritin)Loratadine (Claritin) is approved for children age two is approved for children age two

and over. and over. OTCOTC– Desloratadine (Clarinex)Desloratadine (Clarinex) is similar to Claritin but is similar to Claritin but

significantly more potent and longer lasting. It is significantly more potent and longer lasting. It is available available only by prescriptiononly by prescription..

– Cetirizine (Zyrtec)Cetirizine (Zyrtec) is approved for both indoor and is approved for both indoor and outdoor allergies. It is the only antihistamine to date outdoor allergies. It is the only antihistamine to date approved for infants as young as six months. approved for infants as young as six months. OTCOTC

– Fexofenadine (Allegra) Fexofenadine (Allegra) OTCOTC– Levocetirizine (Xyzal) Levocetirizine (Xyzal) only by prescriptiononly by prescription

• Studies suggest that cetirizine (Zyrtec) is more effective Studies suggest that cetirizine (Zyrtec) is more effective than either of these other agents in improving symptoms, than either of these other agents in improving symptoms, including in children, although cetirizine causes more including in children, although cetirizine causes more drowsiness at higher doses. drowsiness at higher doses.

Allergic Rhinitis: Oral DecongestantsAllergic Rhinitis: Oral Decongestants

• Oral decongestants come in many Oral decongestants come in many brands, which mainly differ in their brands, which mainly differ in their ingredients.ingredients.

• The most common active ingredient The most common active ingredient is is ppseudoephedrine (Sudafed, seudoephedrine (Sudafed, Actifed, Drixoral). The alternative Actifed, Drixoral). The alternative decongestant, phenylpropanolamine decongestant, phenylpropanolamine (PPA) was taken off the market.(PPA) was taken off the market.

Allergic Rhinitis: Oral DecongestantsAllergic Rhinitis: Oral Decongestants

• Side Effects of DecongestantsSide Effects of Decongestants– Agitation and nervousness.Agitation and nervousness.– Drowsiness (particularly with oral Drowsiness (particularly with oral

decongestants and in combination with decongestants and in combination with alcohol).alcohol).

– Changes in heart rate and blood Changes in heart rate and blood pressure.pressure.

– Avoid combinations of oral Avoid combinations of oral decongestants with alcohol or sedatives.decongestants with alcohol or sedatives.

Allergic Rhinitis: Corticosteroid Nasal Allergic Rhinitis: Corticosteroid Nasal

SpraysSprays

• Benefits:Benefits:– The most effective agents currently available for The most effective agents currently available for

treating allergic rhinitis. treating allergic rhinitis. – Blocks the inflammatory response that triggers Blocks the inflammatory response that triggers

an allergic attack. They do not relieve symptoms an allergic attack. They do not relieve symptoms immediately but may take several hours before immediately but may take several hours before their effects are felt. their effects are felt.

– They reduce inflammation and mucus production.They reduce inflammation and mucus production.– They improve night sleep and daytime alertness They improve night sleep and daytime alertness

in patients with perennial allergic rhinitis.in patients with perennial allergic rhinitis.– Beneficial in treating polyps in the nasal Beneficial in treating polyps in the nasal

passages. passages.

Allergic Rhinitis: Corticosteroid Nasal Allergic Rhinitis: Corticosteroid Nasal SpraysSprays

• Corticosteroids available in nasal Corticosteroids available in nasal spray form include the following:spray form include the following:

• Triamcinolone (Nasacort).Triamcinolone (Nasacort). Approved for Approved for children over six, now children over six, now OTC!!!OTC!!!

• Mometasone furoate (Nasonex).Mometasone furoate (Nasonex). Approved for Approved for use in patients as young as three.use in patients as young as three.

• Fluticasone (Flonase).Fluticasone (Flonase). Approved for children Approved for children over four.over four.

• Budesonide (Rhinocort).Budesonide (Rhinocort). Approved for children Approved for children over six.over six.

Nasal AntihistaminesNasal Antihistamines

• Efficacious and equal to or superior to oral Efficacious and equal to or superior to oral antihistamines for treatment of SARantihistamines for treatment of SAR

• Clinically significant effect on nasal Clinically significant effect on nasal congestioncongestion

• Improved nasal symptoms in patients who Improved nasal symptoms in patients who failed oral antihistaminesfailed oral antihistamines

• Onset of action: 30 vs. 60-180 minutes for Onset of action: 30 vs. 60-180 minutes for oral antihistamineoral antihistamine

• Side effects: Sedation, bitter tasteSide effects: Sedation, bitter taste

Nasal AntihistaminesNasal Antihistamines

• Azelastine 0.1% and 0.15% (Astelin, Azelastine 0.1% and 0.15% (Astelin, Astepro)Astepro)

• Olopatadine (Patanase)Olopatadine (Patanase)

• Azelastine/Fluticasone (Dymista)Azelastine/Fluticasone (Dymista)

Allergen ImmunotherapyAllergen Immunotherapy

• Criteria for Allergen Criteria for Allergen ImmunotherapyImmunotherapy– Severity of rhinitis symptomsSeverity of rhinitis symptoms– Duration of rhinitis symptomsDuration of rhinitis symptoms– Progression of rhinitisProgression of rhinitis– Failure to respond to medical treatmentFailure to respond to medical treatment

Allergic Rhinitis: Allergen Allergic Rhinitis: Allergen ImmunotherapyImmunotherapy

• Administering TherapyAdministering Therapy• Immunotherapy requires a prolonged course of Immunotherapy requires a prolonged course of

weekly injections ("allergy shots"). The process weekly injections ("allergy shots"). The process generally follows this course:generally follows this course:– Injections of diluted extracts of the allergen are given on Injections of diluted extracts of the allergen are given on

a regular schedule, usually weekly at first, then in a regular schedule, usually weekly at first, then in increasing doses until a maintenance dose has been increasing doses until a maintenance dose has been reached. It usually takes several months to reach a reached. It usually takes several months to reach a maintenance dose.maintenance dose.

– At that time, intervals between shots can be two to four At that time, intervals between shots can be two to four weeks, and the treatment is continued for up to three to weeks, and the treatment is continued for up to three to five years.five years.

– Patients can experience some relief within three to six Patients can experience some relief within three to six months; if there is no benefit within 18-24 months, the months; if there is no benefit within 18-24 months, the shots should be discontinued.shots should be discontinued.

Allergic Rhinitis:Allergic Rhinitis:ConclusionsConclusions

• Allergic disorders are on the rise and have Allergic disorders are on the rise and have a significant impact on the quality of lifea significant impact on the quality of life

• Allergic rhinitis can lead to other Allergic rhinitis can lead to other comorbidities such as asthma and comorbidities such as asthma and sinusitissinusitis

• Treatment should focus on trigger Treatment should focus on trigger identification and avoidance, medications identification and avoidance, medications and allergen immunotherapyand allergen immunotherapy

ReferencesReferences

• Dykewicz MS, et al. Dykewicz MS, et al. Ann Allergy Asthma Immunol Ann Allergy Asthma Immunol 1998;81(5 Pt 2):478-5181998;81(5 Pt 2):478-518

• Rondon et al. Rondon et al. J Investig Allergol Clin Immunol J Investig Allergol Clin Immunol 2010; 2010; 20(5): 364-37120(5): 364-371

• Wallace et al. Wallace et al. J Allergy Asthma Clin Immunol J Allergy Asthma Clin Immunol 2008; 122: S1-842008; 122: S1-84

• M. Varghese, M. C. Glaum and R. F. Lockey, M. Varghese, M. C. Glaum and R. F. Lockey, Clinical & Experimental AllergyClinical & Experimental Allergy, 2010 (40) 381–, 2010 (40) 381–384384